First Aid/CPR/AED

PARTICIPANT’S MANUAL
Table of Contents
About This Manual vii
Health Precautions and Guidelines During Training viii

CHAPTER 1 Before Giving Care and Checking an Injured or Ill Person 1

Your Role in the EMS System 2
Disease Transmission and Prevention 5
Taking Action: Emergency Action Steps 8
Checking a Conscious Person 14
Shock 16
Checking an Unconscious Person 17
Incident Stress 22
Putting It All Together 23
SKILL SHEET: Removing Gloves 24
SKILL SHEET: Checking an Injured or Ill Adult 25
SKILL SHEET: Checking an Injured or Ill Child or Infant 27

CHAPTER 2 Cardiac Emergencies and CPR _____________________________ 29

Background 30
Heart Attack 30
Cardiac Arrest 33
Putting It All Together 40
SKILL SHEET: CPR—Adult 41
SKILL SHEET: CPR—Child 42
SKILL SHEET: CPR—Infant 43

CHAPTER 3 AED____________________________________________________________ 44
When the Heart Suddenly Fails 45
Using an AED 45
AED Precautions 45
How to Use an AED—Adults 46
How to Use an AED—Children and Infants 47
Special AED Situations 47
Other AED Protocols 49
AED Maintenance 49
Putting It All Together 49
SKILL SHEET: AED—Adult or Child Older Than 8 Years or Weighing More than 55 Pounds 50
SKILL SHEET: AED—Child and Infant Younger Than 8 Years or Weighing Less than 55 Pounds 52

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CHAPTER 4 Breathing Emergencies 54
Background 55
Respiratory Distress and Respiratory Arrest 56
Choking 59
Putting It All Together 65
SKILL SHEET: Conscious Choking—Adult 66
SKILL SHEET: Conscious Choking—Child 67
SKILL SHEET: Conscious Choking—Infant 68
SKILL SHEET: Unconscious Choking—Adult 69
SKILL SHEET: Unconscious Choking—Child and Infant 70

CHAPTER 5 Sudden Illness 71

Sudden Illness 72
Specific Sudden Illnesses 73
Poisoning 79
Putting It All Together 83

CHAPTER 6 Environmental Emergencies 84

Heat-Related Illnesses and Cold-Related Emergencies 85
Bites and Stings 88
Poisonous Plants 98
Lightning 99
Putting It All Together 100

CHAPTER 7 Soft Tissue Injuries 101

Wounds 102
Burns 109
Special Situations 112
Putting It All Together 116
SKILL SHEET: Controlling External Bleeding 117
SKILL SHEET: Using a Manufactured Tourniquet 118

CHAPTER 8 Injuries to Muscles, Bones and Joints 119

Background 120
Types of Injuries 121
Putting It All Together 129
SKILL SHEET: Applying an Anatomic Splint 130
SKILL SHEET: Applying a Soft Splint 132
SKILL SHEET: Applying a Rigid Splint 134
SKILL SHEET: Applying a Sling and Binder 136

First Aid/CPR/AED | Table of Contents v

 CHAPTER 9 Special Situations and Circumstances _____________________ 138
Children and Infants 139
Emergency Childbirth 145
Older Adults 146
People With Disabilities 147
Language Barriers 149
Crime Scenes and Hostile Situations 149
Putting It All Together 150

CHAPTER 10 Asthma _______________________________________________________ 151

Asthma 152
Putting It All Together 154
SKILL SHEET: Assisting With an Asthma Inhaler 155

CHAPTER 11 Anaphylaxis and Epinephrine Auto-Injectors 157

Anaphylaxis 158
Putting It All Together 160
SKILL SHEET: Assisting with an Epinephrine Auto-Injector 161

APPENDIX Injury Prevention and Emergency Preparedness 163

Injuries 164
Putting It All Together 171

Sources 172
Index 175

vi First Aid/CPR/AED | Participant’s Manual

CHAPTER 6
Environmental Emergencies

D
isease, illness and injury are not the only causes of medical emergencies. Much of our environment appears to
be relatively harmless. A weekend outing can bring you closer to the joys of nature: animals, mountains, rivers,
blue skies. But it also can expose you to disease-carrying insects, other biting or stinging creatures and rapid
changes in the weather. Whereas many environmental emergencies can be avoided, even with the best prevention
efforts, emergencies do occur.
In this chapter you will discover how to prevent heat-related illnesses and cold-related emergencies, as well as bites and
stings from insects, spiders and other animals. You also will find information on how to avoid contact with poisonous
plants and how to avoid being struck by lightning. In addition, you will read about when to call for help and how to give
care until help arrives.

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HEAT-RELATED ILLNESSES
AND COLD-RELATED
EMERGENCIES
Exposure to extreme heat or cold can make a person
seriously ill. The likelihood of illness also depends
on factors such as physical activity, clothing, wind,
humidity, working and living conditions, and a person’s
age and state of mind (Fig. 6-1).
Once the signals of a heat-related illness or cold-related FIGURE 6-2 Lightly stretching the muscle and gently massaging the
emergency begin to appear, a person’s condition can area, along with having the person rest and giving electrolyte- and
quickly worsen. A heat-related illness or cold-related carbohydrate-containing fluids, usually is enough for the body to
recover from heat cramps.
emergency can result in death. If you see any of the
signals, act quickly.
People at risk for heat-related illness or a cold-related
What to Look For
emergency include those who work or exercise outdoors, Heat cramps are painful muscle spasms. They usually
elderly people, young children and people with health occur in the legs and abdomen. Think of them as a
problems. Also at risk are those who have had a warning of a possible heat-related illness.
heat-related illness or cold-related emergency in the
past, those with medical conditions that cause poor What to Do
blood circulation and those who take medications to To care for heat cramps, help the person move to
eliminate water from the body (diuretics). a cool place to rest. Give an electrolyte- and
carbohydrate-containing fluid such as a commercial
People usually try to get out of extreme heat or cold
sports drink, fruit juice or milk. Water also may be
before they begin to feel ill. However, some people do
given. Lightly stretch the muscle and gently massage
not or cannot. Athletes and those who work outdoors
the area (Fig. 6-2). The person should not take salt
often keep working even after they begin to feel ill.
tablets. They can worsen the situation.
People living in buildings with poor ventilation, poor
insulation or poor heating or cooling systems are at When cramps stop, the person usually can start activity
increased risk of heat-related illnesses or cold-related again if there are no other signals of illness. He or she
emergencies. Often they might not even recognize that should keep drinking plenty of fluids. Watch the person
they are in danger of becoming ill. carefully for further signals of heat-related illness.

Heat-Related Illness
Heat cramps, heat exhaustion and heat stroke are
conditions caused by overexposure to heat, loss of
fluids and electrolytes.

Heat Cramps
-9˚
Heat cramps are the least severe of the heat-related
illnesses. They often are the first signals that the body
is having trouble with the heat. 9˚

32˚

FIGURE 6-1 Exposure to extreme heat or cold can make a person seriously ill.

CHAPTER 6 | Environmental Emergencies 85

Heat Exhaustion
Heat exhaustion is a more severe condition than heat
cramps. It often affects athletes, firefighters, construction
workers and factory workers. It also affects those who
wear heavy clothing in a hot, humid environment.
What to Look For
Signals of heat exhaustion include cool, moist, pale,
ashen or flushed skin; headache; nausea; dizziness;
weakness; and exhaustion.
What to Do
When a heat-related illness is recognized in its early
stages, it usually can be reversed. Get the person out of
the heat. Move the person to a cooler environment with
circulating air. Loosen or remove as much clothing as
possible and apply cool, wet cloths, such as towels or
sheets, taking care to remoisten the cloths periodically
(Fig. 6-3). Spraying the person with water and fanning
also can help.
If the person is conscious and able to swallow, give
him or her small amounts of a cool fluid such as
a commercial sports drink or fruit juice to restore
fluids and electrolytes. Milk or water also may be given.
Do not let the conscious person drink too quickly.
Give about 4 ounces of fluid every 15 minutes. Let the
person rest in a comfortable position and watch carefully
for changes in his or her condition. The person should
not resume normal activities the same day.
If the person’s condition does not improve or he or she
refuses fluids, has a change in consciousness or vomits,
call 9-1-1 or the local emergency number, as these are
indications that the person’s condition is getting worse.
Stop giving fluids and place the person on his or her side
to keep the airway open. Watch for signals of breathing
problems. Keep the person lying down and continue
to cool the body any way you can (see What to Do Until
Help Arrives).
FIGURE 6-3 When you recognize a heat-related illness, get the
person out of the heat, loosen or remove clothing and apply cool, wet
cloths, such as towels or sheets. Spraying the person with water and
fanning also can be effective.
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Heat Stroke
Heat stroke is the least common but most severe
heat-related illness. It usually occurs when people
ignore the signals of heat exhaustion. Heat stroke
develops when the body systems are overwhelmed
by heat and begin to stop functioning. Heat stroke
is a serious medical emergency.
What to Look For
Signals of heat stroke include extremely high body
temperature, red skin that can be either dry or
moist; changes in consciousness; rapid, weak pulse;
rapid, shallow breathing; confusion; vomiting;
and seizures.
When to Call 9-1-1
Call 9-1-1 or the local emergency number immediately.
Heat stroke is a life-threatening emergency.
What to Do Until Help Arrives
■ Preferred method: Rapidly cool the body by
immersing the person up to the neck in cold water,
if possible.
OR
Douse or spray the person with cold water.
■ Sponge the person with ice water-doused towels
over the entire body, frequently rotating the cold,
wet towels.
■ Cover with bags of ice.
■ If you are not able to measure and monitor the
person’s temperature, apply rapid cooling methods for
20 minutes or until the person’s condition improves.
■ Give care according for other conditions found.
Cold-Related Emergencies
Frostbite and hypothermia are two types of cold-
related emergencies.
Frostbite
Frostbite is the freezing of body parts exposed to the
cold. Severity depends on the air temperature, length
of exposure and the wind. Frostbite can result in the
loss of fingers, hands, arms, toes, feet and legs.
What to Look For
The signals of frostbite include lack of feeling in the
affected area, swelling and skin that appears waxy, is
cold to the touch or is discolored (flushed, white, yellow
or blue). In more serious cases, blisters may form and
the affected part may turn black and show signs of deep
tissue damage.
When to Call 9-1-1
Call 9-1-1 or the local emergency number for more
serious frostbite or seek emergency medical help as soon
as possible.
What to Do Until Help Arrives
To care for frostbite, handle the area gently. Remove
wet clothing and jewelry, if possible, from the affected
area. Never rub a frostbitten area. Rubbing causes
further damage to soft tissues. Do not attempt to
rewarm the frostbitten area if there is a chance that it
might refreeze or if you are close to a medical facility.
For minor frostbite, rapidly rewarm the affected part
using skin-to-skin contact such as with a warm hand.
To care for a more serious injury, gently soak it in water
not warmer than about 105° F (Fig. 6-4, A). If you do not
have a thermometer, test the water temperature yourself.
If the temperature is uncomfortable to your touch, it is
too warm. Keep the frostbitten part in the water until
normal color returns and it feels warm (20 to 30 minutes).
Loosely bandage the area with a dry, sterile dressing
(Fig. 6-4, B). If fingers or toes are frostbitten, place
cotton or gauze between them. Do not break any blisters.
Take precautions to prevent hypothermia. Monitor the
person’s condition, and if you see that the person is going
into shock, give care accordingly. Do not give ibuprofen
or other nonsteroidal anti-inflammatory drugs (NSAIDs)
when caring for frostbite.
Hypothermia
In a hypothermic condition, the entire body cools
because its ability to keep warm is failing. The person
will die if not given the proper care.
The air temperature does not have to be below
freezing for people to develop hypothermia. This is
especially true if the person is wet or if it is windy.
Elderly people in poorly heated homes can develop
hypothermia. The homeless, the ill and young
children also are at risk.
Certain conditions can more easily lead to hypothermia,
including:
■ Ingestion of substances that interfere with the body’s
ability to regulate temperature (such as alcohol, other
drugs and certain medications).
■ Any medical condition that impairs circulation, such
as diabetes or cardiovascular disease.
■ Prolonged exposure to cold, wet and/or windy
conditions or wet clothing.
What to Look For
Signals of hypothermia include the following:
■ Shivering
■ Numbness
■ Glassy stare
■ Indifference
■ Loss of consciousness
Shivering that stops without rewarming is a sign that
the person’s condition is worsening. He or she needs
immediate medical care.
When to Call 9-1-1
Call 9-1-1 or the local emergency number immediately
for any case of hypothermia.

100 - 105 °F

A B

FIGURE 6-4, A–B To care for more serious frostbite: A, Warm the area gently by soaking the affected part in water not warmer than 105˚ F. Keep the
frostbitten part in the water until normal color returns and it feels warm (20–30 minutes). B, Loosely bandage the area with a dry, sterile dressing.

CHAPTER 6 | Environmental Emergencies 87

What to Do Until Help Arrives
To care for hypothermia, start by caring for life-threatening
conditions (see below). Make the person comfortable.
Gently move the person to a warm place. Remove wet
clothing and dry the person. Put on dry clothing. Warm the
body gradually by wrapping the person in blankets and
plastic sheeting to hold in body heat (Fig. 6-5). Also, keep
the head covered to further retain body heat.
If you are far from medical care, position the person
near a heat source or apply heat pads or other heat
sources to the body, such as containers filled with
warm water. Carefully monitor any heat source to
avoid burning the person. Keep a barrier, such as a
blanket, towel or clothing, between the heat source
and the person.
If the person is alert, give warm liquids that do not
contain alcohol or caffeine. Alcohol can cause heat
loss and caffeine can cause dehydration. Do not
warm the person too quickly, such as by immersing
the person in warm water. Check breathing and
monitor for any changes in the person’s condition and
care for shock.
In cases of severe hypothermia, the person may be
unconscious. Breathing may have slowed or stopped.
The body may feel stiff because the muscles became
rigid. Check for breathing for no more than 10 seconds.
If the person is not breathing, perform CPR. Continue
to warm the person until emergency medical services
(EMS) personnel take over. Be prepared to use an
automated external defibrillator (AED), if available.
FIGURE 6-5 For hypothermia, warm the body
gradually by wrapping the person in blankets or
putting on dry clothing and moving him or her to a
warm place. Courtesy of Canadian Red Cross.
88 First Aid/CPR/AED | Participant’s Manual
Preventing Heat-Related Illnesses
and Cold-Related Emergencies
In general, you can prevent illnesses caused by
overexposure to extreme temperatures. To prevent
heat-related illnesses and cold-related emergencies,
follow these guidelines:
■ Do not go outdoors during the hottest or coldest
part of the day.
■ Change your activity level according to the temperature.
■ Take frequent breaks.
■ Dress appropriately for the environment.
■ Drink large amounts of fluids.
BITES AND STINGS
People are bitten and stung every day by insects, spiders,
snakes, animals and marine life. Most of the time,
these bites and stings do not cause serious problems.
However, in rare circumstances, certain bites and stings
can cause serious illness or even death in people who are
sensitive to the venom.
Insect Stings
Most of the time, insect stings are harmless. If the
person is allergic, an insect sting can lead to anaphylaxis,
a life-threatening condition.
What to Look For
Signals of an insect sting include:
■ Presence of a stinger.
■ Pain.
■ Swelling.
■ Signals of an allergic reaction.
What to Do
If someone is stung by an insect:
■ Remove any visible stinger. Scrape it away from the skin
with a clean fingernail or a plastic card, such as a credit
card, or use tweezers (Fig. 6-6). In the case of a bee sting,
if you use tweezers, grasp the stinger, not the venom sac.
■ Wash the site with soap and water.
■ Cover the site and keep it clean.
■ Apply a cold pack to the area to reduce pain and swelling.
■ Call 9-1-1 if the person has any trouble breathing
or for any other signals of anaphylaxis.
Tick-Borne Diseases
Humans can get very sick from the bite of an infected
tick. Some of the diseases spread by ticks include Rocky
Mountain spotted fever, Babesia infection, ehrlichiosis
and Lyme disease.
 FOCUS ON PREVENTION
LAYER YOUR WAY TO WARMTH
As long as seasonal changes and cold climates
exist, preventing cold-related emergencies, such
as hypothermia, remains important when we work
or play outside.
The best way to ensure your comfort and
warmth outdoors is to layer your clothing.
The first layer, called the base layer, is next to
your skin. The base layer helps to regulate your
body temperature by moving perspiration away
from your skin. This is important because if
perspiration gets trapped inside your clothes,
you can become chilled rapidly, which can lead
to hypothermia.
Thermal underwear makes a good base layer for
cold weather. The fabrics that are best at moving
sweat away from the skin (also called wicking) are
silk, merino wool and certain synthetics. Cotton is
not a good choice because it traps moisture rather
than wicking it away.
The job of the middle layer is insulation.
This layer keeps you warm; it helps you retain
heat by trapping air close to your body. Natural
fibers, such as wool and goose down, are excellent
insulators. So is synthetic fleece. Vests, jackets and
FIGURE 6-6 If someone is stung by an insect, scrape the stinger away from the skin
with a clean fingernail or a plastic card, such as a credit card.
tights are examples of clothing that can be worn
for insulation.
The shell or outer layer protects you from wind,
rain or snow. For cold weather, the shell layer
should be both waterproof and “breathable.”
This will keep wind and water from getting inside
of the other two layers while allowing perspiration
to evaporate. The shell also should be roomy enough
to fit easily over the other layers without restricting
your movement.
One of the other advantages of layering is that you
can make quick adjustments if the weather changes
or you change your activity level. You can take
clothes off when you become too warm and put
them back on if you get cold.
In addition to layering your clothes, to stay warm in
cold weather you also should wear:
■ A hat.
■ A scarf or knit mask that covers your face
and mouth.
■ Sleeves that are snug at the wrist.
■ Mittens (they are warmer than gloves).
■ Water-resistant boots.
Rocky Mountain Spotted Fever
Rocky Mountain spotted fever is a bacterial
infection spread by wood ticks in the western
United States, dog ticks in the eastern United
States, and other ticks in the southern United
States. Rocky Mountain spotted fever occurs
mostly in the spring and summer, and most
cases occur in children.
What to Look For
Signals of Rocky Mountain spotted fever
usually appear between 2 and 14 days after a
tick bite.
Initial signals of Rocky Mountain spotted
fever include the following:
■ Fever
■ Nausea
CHAPTER 6 | Environmental Emergencies 89
■ Vomiting Ehrlichiosis
■ Muscle aches or pain Most cases of infection with the bacteria ehrlichia in
■ Lack of appetite humans are caused by bites by an infected Lone Star
■ Severe headache tick, and occur mainly in the southern, eastern and
south-central United States.
Later signals include:
■ Rash: The spotted rash usually starts a few days after What to Look For
fever develops. It first appears as small spots on the Many people with ehrlichiosis do not become ill.
wrists and ankles. It then spreads to the rest of the Some develop only mild signals that are seen
body. However, about one-third of persons infected 5 to 10 days after an infected tick bit the person.
with the illness do not get a rash.
■
Initial signals include the following:
Abdominal pain.
■ Joint pain. ■ Fever
■ Diarrhea. ■ Headache
■ Fatigue
When to Seek Medical Care ■ Muscle aches
Call a health care provider if the person develops Other signals that may develop include the following:
signals of Rocky Mountain spotted fever after a tick bite.
The health care provider is likely to prescribe antibiotics. ■ Nausea
In most cases, the person will recover fully. If left ■ Vomiting
untreated, complications of Rocky Mountain spotted ■ Diarrhea
fever can be life threatening. ■ Cough
■ Joint pains
Babesia Infection
■ Confusion
Babesia also called Babesiosis is a protozoa infection
■ Rash (in some cases)
spread by deer ticks and black-legged ticks. It is more
common during warm months, and most cases happen
in the northeast and upper Midwest regions of the When to Seek Medical Care
United States. If the person becomes ill with any of the above
signals described, he or she should seek medical
What to Look For care. Ehrlichiosis is treated with antibiotics.
Many people infected with Babesia have no apparent
symptoms. Some people may have flu-like symptoms, Lyme Disease
such as: Lyme disease is spreading throughout the United States.
■ Fever Although it is most prevalent on the east coast and
■
the upper Midwest, cases of Lyme disease have been
Sweats
reported in all 50 states.
■ Chills
■ Body aches and headaches Lyme disease is spread by the deer tick and black-legged
■
tick, which attaches itself to field mice and deer. Deer
No appetite
ticks are tiny and difficult to see (Fig. 6-7). They are
■ Nausea much smaller than the common dog tick or wood tick.
■ Fatigue They can be as small as a poppy seed or the head of a
Others infected with Babesia develop a type of anemia pin. Adult deer ticks are only as large as a grape seed.
that can cause jaundice and dark urine. In some people, Because of the tick’s tiny size, its bite usually is painless.
the disease can be life threatening if untreated. The elderly Many people who develop Lyme disease cannot recall
and persons with no spleen, a weak immune system or a having been bitten.
serious health condition are the most susceptible. The tick is found around branches and in wooded
and grassy areas. Like all ticks, it attaches itself to any
When to Seek Medical Care warm-blooded animal with which it comes into direct
If a person develops any of the signals described above, contact, including humans. Deer ticks are active
he or she should seek medical care. Most people with any time the temperature is above about 45° F.
signals of the disease can be treated successfully with However, most cases of infection happen between
prescription medications. May and late August, when ticks are most active and

90 First Aid/CPR/AED | Participant’s Manual

 FIGURE 6-7 Deer ticks are tiny and difficult to see. © iStockphoto
.com/Martin Pietak.
people spend more time outdoors. Recent studies
indicate that the tick must remain embedded in human
skin for about 36 to 48 hours to transmit the disease.
More information on Lyme disease may be available
from your local or state health department, the
American Lyme Disease Foundation (aldf.com), or the
Centers for Disease Control and Prevention (CDC)
(cdc.gov/features/lymedisease/).
What to Look For
The first signal of infection may appear a few days
or a few weeks after a tick bite. In 80 to 90 percent
of all cases of Lyme disease, a rash starts as a small
red area at the site of the bite. It may spread up to
7 inches across (Fig. 6-8). In fair-skinned people,
the center may be a lighter color with the outer edges
red and raised. This sometimes gives the rash a
bull’s-eye appearance. In some individuals, the
rash may appear to be solid red. In dark-skinned
people, the area may look black and blue, like a bruise.
The rash may or may not be warm to the touch and
usually is not itchy or painful. If a rash does appear,
it will do so in about 1 to 2 weeks and may last for about
3 to 5 weeks. Some people with Lyme disease never
develop a rash.
Other signals of Lyme disease include fever, headache,
weakness, and joint and muscle pain. These signals
are similar to signals of flu and can develop slowly.
They might not occur at the same time as the rash.
Lyme disease can get worse if it is not treated.
Signals can include severe fatigue; fever; a stiff,
aching neck; tingling or numbness in the fingers and
toes; and facial paralysis.
In its advanced stages Lyme disease may cause
painful arthritis; numbness in the arms, hands
or legs; severe headaches; long- or short-term
memory loss; confusion; dizziness; and problems
FIGURE 6-8 A person with Lyme disease may develop a rash.
© iStockphoto.com/Heike Kampe.
in seeing or hearing. Some of these signals could
indicate problems with the brain or nervous system.
Lyme disease may also cause heart problems such as
an irregular or rapid heartbeat.
When to Seek Medical Care
If rash or flu-like signals develop, the person should
seek medical care immediately. A health care provider
usually will prescribe antibiotics to treat Lyme disease.
Antibiotics work quickly and effectively if taken as soon
as possible. Most people who get treated early make
a full recovery. If you suspect Lyme disease, do not delay
seeking treatment. Treatment time is longer and less
effective when the person has been infected for a long
period of time.
Preventing Tick-borne Diseases
Follow the guidelines presented in Focus on
Prevention: How to Beat Those Little Critters in
this chapter for general tips on how to prevent contact
with, and bites from, ticks when you are in wooded
or grassy areas.
To prevent tick-borne illnesses, always check for ticks
immediately after outdoor activities. Most experts
believe that the longer the tick stays attached to the skin,
the greater the chances are of infection. Therefore, check
for ticks at least once daily after having been outdoors.
Quickly remove any ticks that you find before they
become swollen with blood.
Wash all clothing. Be sure to check pets because they can
carry ticks into the house, where they can then attach
themselves to people or other pets. Pets also can develop
signals of tick-borne diseases.
If you find a tick embedded in a person’s skin, it must
be removed. With a gloved hand, grasp the tick with
fine-tipped and pointed tweezer that has a smooth inside
CHAPTER 6 | Environmental Emergencies 91

FIGURE 6-9 Remove a tick by pulling slowly, steadily
and firmly with fine-tipped tweezers.
surface. Get as close to the skin as possible. Pull slowly,
steadily and firmly with no twisting (Fig. 6-9).
■ Do not try to burn off the tick.
■ Do not apply petroleum jelly or nail polish
to the tick.
Put the tick in a container or jar with rubbing alcohol
to kill it. Clean the bite area with soap and water and an
antiseptic. Apply an antibiotic ointment if it is available
and the person has no known allergies or sensitivities to
the medication. Encourage the person to seek medical
advice because of the risk of contracting a tick-borne
disease. If you cannot remove the tick, have the person
seek advanced medical care.
Mosquito-Borne Illness:
West Nile Virus
West Nile virus (WNV) is passed on to humans
and other animals by mosquitoes that bite them after
feeding on infected birds. Recently, WNV has been
reported in some mild climate areas of North America
and Europe.
WNV cannot be passed from one person to another.
Also, no evidence supports that humans can acquire
the disease by handling live or dead birds infected with
WNV. However, it is still a good idea to use disposable
gloves when handling an infected bird. Contact your
local health department for instructions on reporting
and disposing of the bird’s body.
For most people, the risk of infection by WNV is very
low. Less than 1 percent of people who are bitten
by mosquitoes develop any signals of the disease.
In addition, relatively few mosquitoes actually carry
WNV. People who spend a lot of time outdoors are
at a higher risk for catching the disease. Only about
1 in every 150 people who are infected with WNV will
become seriously ill.
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Preventing West Nile Virus
The easiest and best way to avoid WNV is to prevent
mosquito bites. Specifically, you can:
■ Use insect repellents containing DEET
(N, N-diethyl-meta-toluamide) when you
are outdoors. Follow the directions on the
package (see Focus on Prevention: Repelling
Those Pests).
■ Consider staying indoors at dusk and dawn, when
mosquitoes are most active. If you have to be outdoors
during these times, use insect repellent and wear long
sleeves and pants. Light-colored clothing can help you
to see mosquitoes that land on you.
■ Make sure you have good screens on your windows
and doors to keep mosquitoes out.
■ Get rid of mosquito breeding sites by emptying
sources of standing water outside of the home,
such as from flowerpots, buckets and barrels.
Also, change the water in pet dishes and replace
the water in bird baths weekly, drill drainage holes
in tire swings so that water drains out and keep
children’s wading pools empty and on their sides
when they are not being used.
For more information, visit cdc.gov/westnile or call the
CDC public response hotline at (888) 246-2675 (English),
(888) 246-2857 (Español) or (866) 874-2646 (TTY).
Source: CDC.gov and redcross.org
What to Look For
Most people infected with WNV have no signals.
Approximately 20 percent develop mild signals,
such as fever and aches, which pass on their own.
The risk of severe disease is higher for people 50 years
and older.
People typically develop signals of WNV between 3 and
14 days after an infected mosquito bites them. Signals of
WNV include the following:
■ High fever
■ Headache
■ Neck stiffness
■ Confusion
■ Coma
■ Tremors
■ Convulsions
■ Muscle weakness
■ Vision loss
■ Numbness
■ Paralysis
These signals may last several weeks. In some cases,
WNV can cause fatal encephalitis, which is a swelling
of the brain that leads to death.
 FOCUS ON PREVENTION
HOW TO BEAT THOSE LITTLE CRITTERS
You can prevent bites and stings from insects,
spiders, ticks or snakes by following these guidelines
when you are in wooded or grassy areas:
■ Wear long-sleeved shirts and long pants.
■ Tuck your pant legs into your socks or boots.
■ Use a rubber band or tape to hold pants
against socks so that nothing can get
under clothing.
■ Tuck your shirt into your pants.
■ Wear light-colored clothing to make it easier
to see tiny insects or ticks.
■ When hiking in woods and fields, stay in
the middle of trails. Avoid underbrush and
tall grass.
■ If you are outdoors for a long time, check
yourself several times during the day.
Especially check in hairy areas of the body
like the back of the neck and the scalp line.
When to Seek Care
If you develop signals of severe WNV illness, such
as unusually severe headaches or confusion, seek
medical attention immediately. Pregnant women
and nursing mothers are encouraged to talk to their
doctors if they develop signals that could indicate
WNV. There is no specific treatment for WNV
infection or a vaccine to prevent it. In more severe
cases, people usually need to go to the hospital, where
they will receive intravenous fluids, assistance with
breathing and nursing care.
A B
FIGURE 6-10, A–B Bites from A, the black widow spider and B, the brown recluse
spider can make a person very sick. Fig. A © iStockphoto.com/Mark Kostich,
Fig. B Image © Miles Boyer, 2010, Used under license from Shutterstock.com.
■ Inspect yourself carefully for insects or
ticks after being outdoors or have someone
else do it.
■ Avoid walking in areas where snakes are
known to live.
■ If you encounter a snake, look around for
others. Turn around and walk away on the
same path on which you came.
■ Wear sturdy hiking boots.
■ If you have pets that go outdoors, spray
them with repellent made for that type of pet.
Apply the repellent according to the label and
check your pet for ticks often.
■ If you will be in a grassy or wooded area
for a long time or if you know that the
area is highly infested with insects or ticks,
consider using a repellent. Follow the
directions carefully.
Spider Bites and Scorpion
Stings
Few spiders in the United States can cause serious
illness or death. However, the bites of the black
widow and brown recluse spiders can, in rare cases,
kill a person (Fig. 6-10, A–B). Another dangerous
spider is the northwestern brown, or hobo,
spider.
Widow spiders can be black, red or brown.
The black widow spider is black with a
reddish hourglass shape on the underside
of its body and is the most venomous of the
widow spiders. The brown recluse spider
(also known as the violin or fiddleback
spider) has a distinctive violin-shaped
pattern on the back of its front body
section.
These spiders prefer dark, out-of-the-way
places. Examples of places where these
spiders live include wood, rock and brush
piles; dark garages; and attics. People often
are bitten on their arms and hands when
reaching into these places.
CHAPTER 6 | Environmental Emergencies 93
 FOCUS ON PREVENTION

REPELLING THOSE PESTS

Insect repellent is used to keep away pests such as
mosquitoes and ticks that sting and bite. DEET is
the active ingredient in many insect repellents. Insect
repellents that contain DEET are available in many
different forms, including sprays, lotions and liquids.
Using repellent with DEET is safe for most people.
However, it is important to follow label directions
and take proper precautions (see below).
The amount of DEET in insect repellents ranges
from less than 10 percent to over 30 percent.
The more DEET that a product contains, the
longer it will protect from mosquito and tick bites.
For example, an insect repellent containing about
24 percent DEET provides about 5 hours of
protection.
Products with 10 percent DEET are as safe
as products with 30 percent DEET when used
properly. Precautions to follow when using products
containing DEET include:
■ Apply products that contain DEET only once
a day.
■ Do not use DEET on infants under 2 months
of age.
■ Do not use a product that combines sunscreen
with a DEET-containing insect repellent.
Sunscreens wash off and need to be
reapplied often. DEET does not wash off with
water. Repeating applications may increase
absorption of the chemical and cause possible
toxic effects.
Before using insect repellent, check the label
carefully for the list of ingredients. If you are unsure
whether the product is safe for you and your family
to use, ask your health care provider. Use caution
when considering insect repellents to be used by
pregnant women, infants and children.
If you use a repellent, follow these general rules:
■ Keep all repellents out of the reach of children.
■ To apply repellent to the face, first spray it on
your hands and then apply it from your hands
to your face. Avoid sensitive areas, such as the
lips and eyes.
■ Never use repellents on an open wound or
irritated skin.
■ Use repellents sparingly. One application will
last 4 to 8 hours. Heavier or more frequent
applications do not increase effectiveness.
■ If you suspect that you are having a reaction to
a repellent, wash the treated skin immediately
and call your health care provider.
■ Never put repellents on children’s hands.
They may put them in their eyes or mouth.
For current information about pesticides, contact the
National Pesticide Information Center at npic.orst.
edu or at (800) 858-7378.

Scorpions live in dry regions such as the southwestern

United States and Mexico. They live under rocks,
logs and the bark of certain trees (Fig. 6-11). They are
most active at night. Like spiders, only a few species
of scorpions have a sting that can cause death. It is
difficult to distinguish highly poisonous scorpions from
nonpoisonous scorpions. Therefore, all scorpion stings
should be treated as medical emergencies.

What to Look For

Signals of spider bites depend on the amount of poison,
called venom, injected and the person’s sensitivity to
the venom. Most spider bites heal with no adverse
effects or scarring. Signals of venomous spider bites
can seem identical to those of other conditions and
FIGURE 6-11 A scorpion. © iStockphoto.com/John Bell.
therefore can be difficult to recognize. The only way

94 First Aid/CPR/AED | Participant’s Manual

to be certain that a spider has bitten a person is to have
witnessed it.
The bite of the black widow spider is the most painful
and deadly of the widow spiders, especially in very
young children and the elderly. The bite usually causes
an immediate sharp pinprick pain, followed by a dull
pain in the area of the bite. However, the person often
does not know that he or she has been bitten until he or
she starts to feel ill or notices a bite mark or swelling.
Other signals of a black widow spider bite include:
■ Rigid muscles in the shoulders, chest, back and
abdomen.
■ Restlessness.
■ Anxiety.
■ Dizziness.
■ Headache.
■ Excessive sweating.
■ ■
Weakness.
■
Drooping or swelling of the eyelids.
The bite of the brown recluse spider may produce little
or no pain initially. Pain in the area of the bite develops
an hour or more later. A blood-filled blister forms under
the surface of the skin, sometimes in a target or bull’s-
eye pattern. Over time, the blister increases in size and
eventually ruptures, leading to tissue destruction and a
black scab.
The hobo spider also can produce an open, slow-healing
wound.
General signals of spider bites and scorpion stings
may include:
■ A mark indicating a possible bite or sting.
■
Severe pain in the sting or bite area.
■ A blister, lesion or swelling at the entry site.
■ ■
Nausea and vomiting.
■ ■
Stiff or painful joints.
■ ■
Chills or fever.
■ Trouble breathing or swallowing or signs
of anaphylaxis.
■ Sweating or salivating profusely.
■ Muscle aches or severe abdominal or back pain.
■
Dizziness or fainting.
■ Chest pain.
■ Elevated heart rate.
■ Infection at the site of the bite.
When to Call 9-1-1
Call 9-1-1 or the local emergency number immediately
if you suspect that someone has been bitten by a black
widow spider or brown recluse spider, stung by a
scorpion or if the person has any other life-threatening
conditions.
What to Do Until Help Arrives
If the person has been bitten by a venomous spider
or stung by a scorpion:
■ Wash the wound thoroughly.
■ Apply an antibiotic ointment, if the person has
no known allergies or sensitivities to the medication,
to prevent infection.
■ Bandage the wound.
■ Apply an ice or cold pack to the site to reduce pain
and swelling.
■ Encourage the person to seek medical attention.
Children and older adults may need antivenin to
block the effects of the spider’s venom.
If you transport the person to a medical facility,
keep the bitten area elevated and as still
as possible.
Venomous Snake Bites
Snakebites kill few people in the United States. Of the
estimated 7000 people bitten annually, fewer than
5 die (Fig. 6-12, A–D). Most snakebites occur near the
home, not in the wild. Rattlesnakes account for most
snakebites, and most of the deaths from snakebites in
the United States. Most deaths occur because the bitten
person has an allergic reaction, is in poor health or
because too much time passes before he or she receives
medical care.
What to Look For
Signals of a possibly venomous snakebite include:
A bite mark.
Pain.
Swelling.
When to Call 9-1-1
If the bite is from a venomous snake such as a
rattlesnake, copperhead, cottonmouth or coral
snake call 9-1-1 or the local emergency number
immediately.
What to Do Until Help Arrives
To care for a venomous snake bite:
■ Wash the wound.
■ Apply an elastic (pressure immobilization) bandage
to slow the spread of venom through the lymphatic
system by following these steps:
CHAPTER 6 | Environmental Emergencies 95
 B
A
A B

C D

FIGURE 6-12, A–D Venomous snakes found in the United Statics include A, rattlesnake (Image © Audrey Snider-Bell, 2010 Used under
license from Shutterstock.com). B, copperhead (© iStockphoto.com/Jake Holmes), C, cottonmouth (Image © Leighton Photography &
Imaging, 2010 Used under license from Shutterstock.com), and D, coral snake (© iStockphoto.com/Mark Kostich).

{ Check for feeling, warmth and color of the
limb and note changes in skin color and
temperature.
{ Place the end of the bandage against the skin and
use overlapping turns.
{ The wrap should cover a long body section,
such as an arm or a calf, beginning at the point
farthest from the heart. For a joint, such as the
knee or ankle, use figure-eight turns to support
the joint.
{ Check above and below the injury for feeling,
warmth and color, especially fingers and toes,
after you have applied an elastic roller bandage.
By checking before and after bandaging, you may
be able to tell if any tingling or numbness is from
the elastic bandage or the injury.
{ Check the snugness of the bandaging—a finger
should easily, but not loosely, pass under the
bandage.
{ Keep the injured area still and lower than the
heart. The person should walk only if absolutely
necessary.
■
Do not apply ice.
■ Do not cut the wound.
■ Do not apply suction.
■ Do not apply a tourniquet.
■ Do not use electric shock, such as from a car battery.
Animal Bites
The bite of a domestic or wild animal can cause infection
and soft tissue injury. The most serious possible result
is rabies. Rabies is transmitted through the saliva of
diseased animals such as skunks, bats, raccoons, cats,
dogs, cattle and foxes.
Animals with rabies may act strangely. For example, those
that are usually active at night may be active in the daytime.
A wild animal that usually tries to avoid people might
not run from you. Rabid animals may drool, appear to be
partially paralyzed, or act aggressively or strangely quiet.
If not treated, rabies is fatal. Anyone bitten by an animal
that might have rabies must get medical attention.
Treatment for rabies includes a series of vaccine injections
to build up immunity that will help fight the disease.
If an animal bites someone, try to get the person away
from the animal without putting yourself in danger. Do
not try to stop, hold or catch the animal. Do not touch
a pet that may have come in contact with the animal’s
saliva without using or wearing some form of protection
like disposable gloves.

96 First Aid/CPR/AED | Participant’s Manual

What to Look For
Signals of an animal bite include:
■ A bite mark.
■ Bleeding.
When to Call 9-1-1
Call 9-1-1 or the local emergency number if the wound
is bleeding seriously or you suspect the animal might
have rabies.
If possible, try to remember the animal’s appearance
and where you last saw it. When you call 9-1-1 or the
local emergency number, the call taker will direct the
proper authorities, such as animal control, to the scene.
What to Do Until Help Arrives
To care for an animal bite:
■ Control bleeding first if the wound is bleeding seriously.
■ Do not clean serious wounds. The wound will be
cleaned at a medical facility.
■ If bleeding is minor, wash the wound with soap and
water then irrigate with clean running tap water.
■ Control any bleeding.
■ Apply an antibiotic ointment to a minor wound,
if the person has no known allergies or sensitivities
to the medication, and cover the wound with a
dressing.
■ Watch for signals of infection.
Marine Life Stings
The stings of some forms of marine life are not only
painful, but they can make you sick, and in some
parts of the world, can kill you (Fig. 6-13, A–D).
The side effects include allergic reactions that can cause
breathing and heart problems, as well as paralysis and
death. The lifeguards in your area should know the
types of jellyfish that may be present.
What to Look For
Signals of marine life stings include:
■ Possible puncture marks.
■ Pain.
■ Swelling.
■ Signs of a possible allergic reaction.

B
A B

C D

FIGURE 6-13, A–D The painful sting of some marine animals can cause serious problems: A, stingray (© iStockphoto.com/Dia Karanouh);
B, Bluebottle jellyfish/Portuguese man-of-war (© iStockphoto.com/Mark Kostich); C, sea anemone (© iStockphoto.com/Omers); D, jellyfish (Image
© Johan1900, 2010 Used under license from Shutterstock.com).

CHAPTER 6 | Environmental Emergencies 97

When to Call 9-1-1
Call 9-1-1 or the local emergency number if the
person does not know what stung him or her, has
a history of allergic reactions to marine-life stings,
is stung on the face or neck, or starts to have
trouble breathing.
What to Do Until Help Arrives
If you encounter someone who has a marine-life sting:
■ Get a lifeguard to remove the person from the
water as soon as possible. If a lifeguard is not
available, use a reaching assist, if possible (see
Chapter 1). Avoid touching the person with your
bare hands, which could expose you to the stinging
tentacles. Use gloves or a towel when removing
any tentacles.
■ If you know the sting is from a jellyfish, irrigate the
injured part with large amounts of vinegar as soon
as possible for at least 30 seconds. This can help
to remove the tentacles and stop the injection of
venom. Vinegar works best to offset the toxin, but
a baking soda slurry also may be used if vinegar is
not available.
■ If the sting is known to be from a bluebottle jellyfish,
also known as a Portugese man-of-war, use ocean
water instead of vinegar. Vinegar triggers further
envenomation.
B C
FIGURE 6-14, A–C A, poison ivy (Image © Tim Mainiero, 2010 Used under license from Shutterstock.com);
B, poison sumac (Courtesy of www.poison-ivy.org); C, poison oak (Image © Dwight Smith, 2010 Used under
license from Shutterstock.com).
98 First Aid/CPR/AED | Participant’s Manual
■ Do not rub the wound, apply a pressure
immobilization bandage or apply fresh water or
other remedies because this may increase pain.
■ Once the stinging action is stopped and tentacles
removed, care for pain by hot-water immersion.
Have the person take a hot shower if possible for at
least 20 minutes. The water temperature should be
as hot as can be tolerated (non-scalding) or about
113° F if the temperature can be measured.
■ If you know the sting is from a stingray, sea urchin
or spiny fish, flush the wound with tap water.
Ocean water also may be used. Keep the injured
part still and soak the affected area in non-scalding
hot water (as hot as the person can stand) for at
least 20 minutes or until the pain goes away. If
hot water is not available, packing the area in hot
sand may have a similar effect if the sand is hot
enough. Then carefully clean the wound and apply
a bandage. Watch for signals of infection and
check with a health care provider to determine if a
tetanus shot is needed.
POISONOUS PLANTS
Every year, millions of people suffer after coming
into contact with poisonous plants such as poison
ivy, poison sumac and poison oak (Fig. 6-14, A–C).
You often can avoid or limit the irritating effects of
touching or brushing against poisonous plants by
following these steps:
■ Remove exposed clothing and wash the exposed area
thoroughly with soap and water as soon as possible
after contact.
■ Wash clothing exposed to plant oils since the oils can
linger on fabric. Wash your hands thoroughly after
handling exposed clothing. Wash your hands after
touching exposed pets.
■ Put a paste of baking soda and water on the area
several times a day if a rash or weeping sore begins to
develop. Calamine lotion and antihistamines, such as
Benadryl®, may help to dry up the sores.
■ See a health care provider if the condition gets worse
or involves areas of the face or throat that could
affect breathing. He or she may decide to give anti-
inflammatory drugs, such as corticosteroids or other
medications, to relieve discomfort.
LIGHTNING
Every year, lightning causes more deaths in the United
States than any other weather hazard, including
blizzards, hurricanes, floods, tornadoes, earthquakes
and volcanic eruptions. The National Weather Service
(NWS) estimates that lightning kills nearly 100 people
annually and injures about 300 others.
Lightning travels at speeds of up to 300 miles per second.
Anything tall—a tower, tree or person—can become a
path for the electrical current. A lightning strike can
throw a person through the air, burn off clothes and
cause the heart to stop beating. The most severe lightning
strikes carry up to 50 million volts of electricity. This
is enough electricity to light 13,000 homes. Lightning
can “flash” over a person’s body or it can travel through
blood vessels and nerves to reach the ground.
If a person survives a lightning strike, he or she may
act confused. The person may describe the episode
as getting hit on the head or hearing an explosion.
Prevent Lightning Injuries
What to do before a possible lightning storm:
■ Pick campsites that meet safety precautions.
■ Know local weather patterns, especially in summertime.
■ Plan turnaround times (the amount of time you need
to get back) in lightning-prone areas, based on your
research, and stick to the plan.
During thunderstorms, use common sense to prevent
being struck by lightning. If a thunderstorm threatens,
the NWS advises people to:
■ Postpone activities immediately, and not wait
for rain to begin. Thunder and lightning can strike
without rain.
■ Watch cloud patterns and conditions for signs of an
approaching storm.
■ Designate safe locations and move or
evacuate to a safe location at the first sound
of thunder. Every 5 seconds between the flash
of lightning and the sound of thunder equals
1 mile of distance.
■ Where possible, quickly find shelter in a substantial
building (not a carport, open garage or covered patio),
or in a fully enclosed metal vehicle, such as a hardtop
car (not a convertible), truck or van, with the windows
completely shut.
■ Use the 30-30 rule where visibility is good and
there is nothing obstructing your view of the
thunderstorm. When you see lightning, count the
time until you hear thunder. If that time is
30 seconds or less, the thunderstorm is within
6 miles. Seek shelter immediately. The threat of
lightning continues for a much longer period than
most people realize. Wait at least 30 minutes after
the last clap of thunder before leaving shelter.
If inside during a storm, keep away from windows.
Injuries may occur from flying debris or glass if
a window breaks.
■ Stay away from plumbing, electrical equipment and
wiring during a thunderstorm.
■ Do not use a corded telephone or radio transmitter
except for emergencies.
■ If there is a tornado alert, go to the basement of the
lowest interior level of a building.
In a lightning storm, reach safety by following these
guidelines:
■ Move downhill.
■ Do not stay in a meadow or any other
wide-open space.
■ Seek uniform cover, such as low rolling hills or trees
of about the same size.
■ If you are boating or swimming, get to land and move
away from the shore.
■ Avoid all of the following:
{ Metal
{ Anything connected to electrical power
{ High places and high objects such as
tall trees
{ Open places
{ Damp, shallow caves and tunnels
{ Overhangs
{ Flood zones
CHAPTER 6 | Environmental Emergencies 99

FIGURE 6-15 If lightning strikes and you cannot get inside, squat or
sit in a tight body position, preferably on insulating material such as a
sleeping pad or life jacket. Courtesy of the Canadian Red Cross.
{ Places obviously struck by lightning in the past
{ Long conductors, such as fences
If lightning is striking nearby when people are outside,
they should assume a safe position:
■ Squat or sit in a tight body position on insulating
material such as a sleeping pad or a life jacket (Fig. 6-15).
■ Take off any metal-framed packs and toss hiking poles
away from the group.
■ Do not lie down; instead, try to make as little contact
with the ground as possible.
■ If you feel your hair stand on end or your skin get
tingly, cover your ears with your hands, close your
eyes and get your head close to your knees.
■ Avoid squatting or sitting close to other people.
Maintain a minimum distance of at least 15 feet
between people. Keep everyone in sight if possible.
Lightning Injuries
Lightning injuries are serious and can be fatal. Being
struck by lightning can cause cardiac and pulmonary
arrest, neurological problems, blindness, deafness, burns,
bone fractures, loss of hearing, eyesight and trauma.
What to Look For
When checking a person struck by lightning, look the
person over from head to toe in the front and back for
any of the following signals:
100 First Aid/CPR/AED | Participant’s Manual
■ Unconsciousness
■ Dazed, confused behavior
■ Trouble breathing
■ No breathing
■ Burn marks on the skin or other open wounds
■ Muscle, bone or joint injuries such as fractures
or dislocations
When to Call 9-1-1
Call 9-1-1 immediately if a person is struck
by lightning.
Even if the person seems to have recovered soon after
the incident, advanced medical care still is necessary
because serious problems can develop later.
What to Do Until Help Arrives
■ Immediately perform CPR if needed.
■ Give care for any injuries as needed including care
for thermal burns.
■ Be ready to care for other conditions, such as
hypothermia in a wet, injured person.
PUTTING IT ALL TOGETHER
Outdoor activities in all kinds of weather are healthy
and fun, but environmental emergencies can occur.
Children and adults become seriously injured, and
even die, from heat stroke, hypothermia, snakebites
and lightning strikes.
The good news is that you can prevent environmental
emergencies most of the time. Be prepared for all kinds
of weather and situations before you head out to hike,
swim, ski or camp. Know how to dress appropriately,
what precautions to take and what to do if a situation
becomes uncertain.
Even with excellent preparation, emergencies still
happen. Know the signals—especially the early ones—of
environmentally caused illnesses. This will allow you
to make quick decisions for yourself or others. Quick
decisions about when to call 9-1-1 and when to seek
medical care can mean the difference between life and
death in an environmental emergency!